1972273282 NPI number — OPERATION LIFESTYLE REDESIGN GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972273282 NPI number — OPERATION LIFESTYLE REDESIGN GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPERATION LIFESTYLE REDESIGN GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972273282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 DIXWELL AVE STE 278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511-3403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-957-3938
Provider Business Mailing Address Fax Number:
866-266-4842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
83 WOOSTER HEIGHTS
Provider Second Line Business Practice Location Address:
SUITE #125
Provider Business Practice Location Address City Name:
DANBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-957-3938
Provider Business Practice Location Address Fax Number:
866-266-4842
Provider Enumeration Date:
09/17/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PERVIS
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
DAVAR
Authorized Official Title or Position:
VICE PRESIDENT OF CLINICAL OPERATIO
Authorized Official Telephone Number:
203-957-3938

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)